544767 research-article2014
ISP0010.1177/0020764014544767International Journal of Social PsychiatryLam and Johnston
E CAMDEN SCHIZOPH
Article
Depression and health-seeking behaviour among migrant workers in Shenzhen
International Journal of Social Psychiatry 2015, Vol. 61(4) 350–357 © The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0020764014544767 isp.sagepub.com
Kelvin KF Lam and Janice M Johnston
Abstract Background: This study describes the prevalence of depression symptoms and its impact on health-seeking behaviour among Chinese migrant workers in a sample of 1,533 Shenzhen residents. Methods: A cross-sectional questionnaire survey was administered in Shenzhen with a random sample of 859 registered and 674 non-registered residents. The 20-item Centre for Epidemiologic Studies–Depression Scale (CES-D) scale was used to measure depression symptoms. Multivariate regression analysis was applied to assess healthcare services utilisation. Results: Non-registered residents were more likely to have clinically significant depressive symptoms (CES-D score ≥ 16) (odds ratio (OR) = 1.81; confidence interval (CI) = 1.18, 2.76). Despite this, depressed non-registered residents had no significant difference in health-seeking behaviour when compared to those without depression (OR = 2.86; CI = 0.98, 8.32), while in contrast, depressed registered residents had a positive and stronger association with healthcare services utilisation and/or self-medication (OR = 3.34; CI = 1.28, 8.71). Conclusion: The findings suggest higher prevalence of depression but less utilisation of healthcare services or selfmedication among migrant residents. That migrants with depression lack access to healthcare suggests healthcare inequality. Psychological disorders require careful management and treatment; the mismatch in their health needs and access to care may contribute to the Inverse-care law. Keywords Depression, Centre for Epidemiologic Studies–Depression Scale, migrant, healthcare utilisation
Introduction China has one of the largest cohorts of internal migrants, commonly known as the ‘floating population’. This floating population has been the backbone of China’s quintessential growth in recent decades, rising from about 50–60 million in the early 1990s to well over 250 million in 2013 (National Bureau of Statistics of China, 2013; Rozelle, Guo, Shen, Hughart, & Giles, 1999; Yang, 1996). China’s unique hukou (registration) system, which characterises an individual’s identity as well as his or her social entitlements such as healthcare, education and pension, plays a defining role in this internal movement (Chan, 1996). As migrants typically hold the hukou of their birthcity, they often find themselves restricted in their access to healthcare and social support services in the city where they work. Initially, this system worked well to control internal migration, but with the 1979 economic reforms and a relaxation of migration and travelling policies, inequalities and inequity in the distribution of resources between local and non-local hukou residents has been observed, particularly in large cities attracting scores of workers.
Shenzhen provides a unique natural experiment to discern the benefits and potential drawbacks of rapid urbanisation of migrant populations. From a small fishing village with a gross domestic product (GDP) of RMB 196 million in 1979, to a GDP of RMB 958 billion in 2011, Shenzhen boasts a staggering annual growth rate of 25.3% (Shenzhen Municipal Government, 2011). A similar growth in the population size and structure was also noted, with a population of only 1,500 non-registered residents in 1979 to 7.9 million in 2011, representing an annual average growth rate of 31.8% compared with only 7% for registered residents (Shenzhen Municipal Government, 2011).The health and social problems associated with population migration School of Public Health, Faculty of Medicine, The University of Hong Kong, Hong Kong Corresponding author: Janice M Johnston, School of Public Health, Faculty of Medicine, The University of Hong Kong, 5/F William MW Mong Block, 21 Sassoon Road, Hong Kong. Email: [email protected]
Downloaded from isp.sagepub.com at RUTGERS UNIV on August 11, 2015
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Lam and Johnston in China are well-documented, and include increased communicable and non-communicable diseases, occupational health problems, increased socio-economic disparity, engagement in health risk behaviour and reduced access to healthcare services (Lam & Johnston, 2012; Mou et al., 2009; Mou, Fellmeth, Griffiths, Dawes, & Cheng, 2012; Van Doorslaer et al., 2007). Elsewhere, migrants are at higher risk for mental health disorders particularly depression and anxiety (Aroian & Norris, 2003; Cuellar, Bastida, & Braccio, 2004; Murray & Williams, 1986). Few studies have reported the mental health status of migrants in China (Chen, Zhang, & Chen, 2006; Lin, Fang, & Lin, 2006; Qiu et al., 2011). As Shenzhen hosts the largest floating populations in Southern China, and as highlighted by a number of high-profile migrant-worker-related suicides (Cheng, Chen, & Yip, 2011), the mental health status of migrants is of public health concern. Depression-related disability can have a severe impact on both individuals and society; in turn, individuals with depressive symptoms have greater health needs for the management and treatment of the illness. In support of the World Health Organization’s (2010) initiative on migrant research on non-communicable disease and mental health, we set out to compare the prevalence of depressive symptoms between migrant and registered residents in Shenzhen, and in turn assess the accessibility to health services as proxied by health service utilisation.
Methods Sampling and subject recruitment The sampling procedure is similar to our previous study and briefly described here. The sample population in this study was recruited via a cross-sectional telephone survey targeting all households with a residential telephone number in Shenzhen. Each telephone number was randomly generated by computer with the local prefix (+86 755), and each valid number was attempted a minimum of three times at different times of the day. Upon successful contact, a household member 18 years or above who spoke Mandarin, Cantonese or English was recruited for the study. The survey was conducted in December 2012 by trained and blinded interviewers from the Social Science Research Centre of the University of Hong Kong.
Survey instrument The Centre for Epidemiologic Studies–Depression Scale (CES-D) (Radloff, 1977) was added to the validated 65-question survey instrument for socio-demographic characteristics, self-reported health status, health-seeking behaviour and healthcare services utilisation used in the previous study (Lam & Johnston, 2012). The CES-D is a 20-item self-report scale designed to measure depressive
symptoms such as ‘restless sleep’, ‘poor appetite’ and/or ‘feeling lonely’ in the general population. CES-D has been validated in many sample populations (Maiano, Morin, & Begarie, 2011; Thombs et al., 2008; Wada et al., 2007), including Chinese populations (Yuan, Chen, & Zhu, 1998; Zhang, Tang, & Liu, 2004). Respondents rate symptoms on a four-point Likert scale, ranging from zero to three – (0) rarely or none of the time, (1) some of little of the time, (2) occasionally or a moderate amount of the time and (3) most or all of the time – with a total aggregate score ranging from 0 to 60. A CES-D score threshold of 16 or greater indicates the likely presence of clinically significant depressive symptoms (Lewinsohn, Seeley, Roberts, & Allen, 1997; Radloff, 1977), and 21 or greater is highly suggestive of a clinical diagnosis of depression (Lyness et al., 1997).
Data analysis The primary outcome variables were individual and aggregate CES-D scores and healthcare utilisation by registration status. Confirmatory factor analysis was conducted to examine the factor structure of the CES-D scale for the two registration status groups. Factor analysis using Stata (StataCorp) Version 12 software was employed to replicate the CES-D factors originally described by (Radloff, 1977), and the proposed four factors of the structure were depressed, somatic, positive and interpersonal. To determine whether the factor structure was supported by our data, a number of indices measuring model fit were used, including the likelihood ratio χ2 statistic and degrees of freedom (Carmines & McIver, 1983), comparative fit index (CFI), root mean square error of approximation (RMSEA) (Browne & Cudeck, 1992), Tucker–Lewis index (TLI) (Tucker & Lewis, 1973) and the coefficient of determination (CD) (Steel & Torrie, 1960). In brief, RMSEA values of
ISP0010.1177/0020764014544767International Journal of Social PsychiatryLam and Johnston
E CAMDEN SCHIZOPH
Article
Depression and health-seeking behaviour among migrant workers in Shenzhen
International Journal of Social Psychiatry 2015, Vol. 61(4) 350–357 © The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0020764014544767 isp.sagepub.com
Kelvin KF Lam and Janice M Johnston
Abstract Background: This study describes the prevalence of depression symptoms and its impact on health-seeking behaviour among Chinese migrant workers in a sample of 1,533 Shenzhen residents. Methods: A cross-sectional questionnaire survey was administered in Shenzhen with a random sample of 859 registered and 674 non-registered residents. The 20-item Centre for Epidemiologic Studies–Depression Scale (CES-D) scale was used to measure depression symptoms. Multivariate regression analysis was applied to assess healthcare services utilisation. Results: Non-registered residents were more likely to have clinically significant depressive symptoms (CES-D score ≥ 16) (odds ratio (OR) = 1.81; confidence interval (CI) = 1.18, 2.76). Despite this, depressed non-registered residents had no significant difference in health-seeking behaviour when compared to those without depression (OR = 2.86; CI = 0.98, 8.32), while in contrast, depressed registered residents had a positive and stronger association with healthcare services utilisation and/or self-medication (OR = 3.34; CI = 1.28, 8.71). Conclusion: The findings suggest higher prevalence of depression but less utilisation of healthcare services or selfmedication among migrant residents. That migrants with depression lack access to healthcare suggests healthcare inequality. Psychological disorders require careful management and treatment; the mismatch in their health needs and access to care may contribute to the Inverse-care law. Keywords Depression, Centre for Epidemiologic Studies–Depression Scale, migrant, healthcare utilisation
Introduction China has one of the largest cohorts of internal migrants, commonly known as the ‘floating population’. This floating population has been the backbone of China’s quintessential growth in recent decades, rising from about 50–60 million in the early 1990s to well over 250 million in 2013 (National Bureau of Statistics of China, 2013; Rozelle, Guo, Shen, Hughart, & Giles, 1999; Yang, 1996). China’s unique hukou (registration) system, which characterises an individual’s identity as well as his or her social entitlements such as healthcare, education and pension, plays a defining role in this internal movement (Chan, 1996). As migrants typically hold the hukou of their birthcity, they often find themselves restricted in their access to healthcare and social support services in the city where they work. Initially, this system worked well to control internal migration, but with the 1979 economic reforms and a relaxation of migration and travelling policies, inequalities and inequity in the distribution of resources between local and non-local hukou residents has been observed, particularly in large cities attracting scores of workers.
Shenzhen provides a unique natural experiment to discern the benefits and potential drawbacks of rapid urbanisation of migrant populations. From a small fishing village with a gross domestic product (GDP) of RMB 196 million in 1979, to a GDP of RMB 958 billion in 2011, Shenzhen boasts a staggering annual growth rate of 25.3% (Shenzhen Municipal Government, 2011). A similar growth in the population size and structure was also noted, with a population of only 1,500 non-registered residents in 1979 to 7.9 million in 2011, representing an annual average growth rate of 31.8% compared with only 7% for registered residents (Shenzhen Municipal Government, 2011).The health and social problems associated with population migration School of Public Health, Faculty of Medicine, The University of Hong Kong, Hong Kong Corresponding author: Janice M Johnston, School of Public Health, Faculty of Medicine, The University of Hong Kong, 5/F William MW Mong Block, 21 Sassoon Road, Hong Kong. Email: [email protected]
Downloaded from isp.sagepub.com at RUTGERS UNIV on August 11, 2015
351
Lam and Johnston in China are well-documented, and include increased communicable and non-communicable diseases, occupational health problems, increased socio-economic disparity, engagement in health risk behaviour and reduced access to healthcare services (Lam & Johnston, 2012; Mou et al., 2009; Mou, Fellmeth, Griffiths, Dawes, & Cheng, 2012; Van Doorslaer et al., 2007). Elsewhere, migrants are at higher risk for mental health disorders particularly depression and anxiety (Aroian & Norris, 2003; Cuellar, Bastida, & Braccio, 2004; Murray & Williams, 1986). Few studies have reported the mental health status of migrants in China (Chen, Zhang, & Chen, 2006; Lin, Fang, & Lin, 2006; Qiu et al., 2011). As Shenzhen hosts the largest floating populations in Southern China, and as highlighted by a number of high-profile migrant-worker-related suicides (Cheng, Chen, & Yip, 2011), the mental health status of migrants is of public health concern. Depression-related disability can have a severe impact on both individuals and society; in turn, individuals with depressive symptoms have greater health needs for the management and treatment of the illness. In support of the World Health Organization’s (2010) initiative on migrant research on non-communicable disease and mental health, we set out to compare the prevalence of depressive symptoms between migrant and registered residents in Shenzhen, and in turn assess the accessibility to health services as proxied by health service utilisation.
Methods Sampling and subject recruitment The sampling procedure is similar to our previous study and briefly described here. The sample population in this study was recruited via a cross-sectional telephone survey targeting all households with a residential telephone number in Shenzhen. Each telephone number was randomly generated by computer with the local prefix (+86 755), and each valid number was attempted a minimum of three times at different times of the day. Upon successful contact, a household member 18 years or above who spoke Mandarin, Cantonese or English was recruited for the study. The survey was conducted in December 2012 by trained and blinded interviewers from the Social Science Research Centre of the University of Hong Kong.
Survey instrument The Centre for Epidemiologic Studies–Depression Scale (CES-D) (Radloff, 1977) was added to the validated 65-question survey instrument for socio-demographic characteristics, self-reported health status, health-seeking behaviour and healthcare services utilisation used in the previous study (Lam & Johnston, 2012). The CES-D is a 20-item self-report scale designed to measure depressive
symptoms such as ‘restless sleep’, ‘poor appetite’ and/or ‘feeling lonely’ in the general population. CES-D has been validated in many sample populations (Maiano, Morin, & Begarie, 2011; Thombs et al., 2008; Wada et al., 2007), including Chinese populations (Yuan, Chen, & Zhu, 1998; Zhang, Tang, & Liu, 2004). Respondents rate symptoms on a four-point Likert scale, ranging from zero to three – (0) rarely or none of the time, (1) some of little of the time, (2) occasionally or a moderate amount of the time and (3) most or all of the time – with a total aggregate score ranging from 0 to 60. A CES-D score threshold of 16 or greater indicates the likely presence of clinically significant depressive symptoms (Lewinsohn, Seeley, Roberts, & Allen, 1997; Radloff, 1977), and 21 or greater is highly suggestive of a clinical diagnosis of depression (Lyness et al., 1997).
Data analysis The primary outcome variables were individual and aggregate CES-D scores and healthcare utilisation by registration status. Confirmatory factor analysis was conducted to examine the factor structure of the CES-D scale for the two registration status groups. Factor analysis using Stata (StataCorp) Version 12 software was employed to replicate the CES-D factors originally described by (Radloff, 1977), and the proposed four factors of the structure were depressed, somatic, positive and interpersonal. To determine whether the factor structure was supported by our data, a number of indices measuring model fit were used, including the likelihood ratio χ2 statistic and degrees of freedom (Carmines & McIver, 1983), comparative fit index (CFI), root mean square error of approximation (RMSEA) (Browne & Cudeck, 1992), Tucker–Lewis index (TLI) (Tucker & Lewis, 1973) and the coefficient of determination (CD) (Steel & Torrie, 1960). In brief, RMSEA values of
